Posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors often occur together (e.g., Holliday et al., 2020; May & Klonsky, 2016; Roberge et al., 2020). There are numerous evidence-based treatments (EBTs) for treating PTSD and preventing suicide, but despite the common co-occurrence of these mental health concerns, suicide and PTSD are often treated independently. In fact, past clinical guidelines have recommended against using trauma-focused treatments for patients at high-risk for suicide due to concerns for increasing risk for suicide. This could lead to missed opportunities to address suicidality among people with PTSD or prevent access to quality PTSD care among suicidal people. A clearer understanding of how treating PTSD impacts suicidality and, conversely, how targeting suicidality improves PTSD is critical for treatment planning for this at-risk population.
We systematically reviewed the scientific literature to examine the impact of treatments designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search resulted in a total of 33 articles:
- 23 studies examined PTSD treatments, all of which are trauma-focused except one (Present Centered Therapy), which were associated with reductions in PTSD- and suicide-related outcomes.
- 11 studies included Cognitive Processing Therapy (CPT)
- 9 studies included Prolonged Exposure (PE)
- 4 studies included Eye Movement Desensitization and Reprocessing (EMDR)
- 2 studies included Present Centered Therapy (PCT)
- 1 study included Narrative Exposure Therapy (NET)
- 2 studies included Concurrent Treatment of PTSD and Substance Use Disorders (COPE)
- 6 studies examined combined PTSD & suicide treatments, which were associated with reductions in PTSD- and suicide-related outcomes.
- 6 articles included various formats (e.g., sequential vs. integrative) of combined Dialectical Behavior Therapy (DBT) and exposure therapy (e.g., DBT-PE, DBT-PTSD)
- 4 studies examined suicide-specific treatments, which were associated with reductions in suicide-related outcomes, but showed mixed results for PTSD symptoms.
- 1 study included Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT)
- 2 studies included Post-Admission Cognitive Therapy for the Prevention of Suicide (PACT)
- 4 studies included Dialectical Behavioral Therapy (DBT)
These findings support current clinical guidelines for PTSD and suicide, which most strongly recommend trauma-focused treatments for PTSD and suggest utilizing PTSD treatments for individuals at risk for suicide (VA/DOD, 2017, 2019). Overall, these results indicate that EBTs for PTSD can and do effectively reduce suicidal thoughts and/or behaviors.
Based on the findings of this review, a promising avenue may be to integrate suicide-specific intervention into PTSD treatment. An integrative approach may reduce the overall burden of treatment (e.g., time in treatment, cost, etc.) on patients and providers as well as promote the inclusion of individuals at risk for suicide and who have PTSD to be included in evidence-based trauma-focused treatment (Rozek & Bryan, 2020).
We hope these findings will inform researchers, clinicians, and policy makers about the available data related to the various treatment options for individuals with PTSD and heightened suicide risk.
Target Article
Rozek, D. C., Baker, S. N., Rugo, K. F., Steigerwald, V. L., Sippel, L. M., Holliday, R., Roberge, E. M., Held, P., Mota, N., & Smith, N. B. (2021). Addressing co‐occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence‐based psychotherapies for adults: A systematic review. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.22774
Discussion Questions
- How can we integrate suicide-focused interventions into evidence-based trauma-focused treatment?
- What are your concerns regarding treating individuals with PTSD who are also at increased risk for suicide?
- How can we ethically promote the inclusion of individuals at heightened risk for suicide and who have PTSD in research settings?
About the Authors
David Rozek, PhD, ABPP, is an assistant professor at UCF RESTORES and the Department of Psychology at the University of Central Florida. Dr. Rozek’s research and clinical expertise are in cognitive and behavioral therapies for suicide, depression, and PTSD. He regularly provides training to clinicians and medical professionals about managing suicidal patients and is an active researcher focusing on how to best improve clinical care. Dr. Rozek can be contacted at david.rozek@ucf.edu and he can be found on Twitter @davidrozekphd.
Shelby Baker, B.S., B.A., is a doctoral student in the Clinical Psychology PhD Program at the University of Central Florida and a member of UCF RESTORES. Her research focuses on improving treatments for PTSD and suicide as well as understanding the intersection between physical symptomology and suicidal thoughts and behaviors. She can be contacted at shelby.baker@knights.ucf.edu and found on Twitter at @shelb_baker.
Kelsi Rugo, MS, is a clinical psychology student at the University of Utah, currently completing her pre-doctoral internship at the Salt Lake City VA Medical Center. She has a master's degree in Clinical Mental Health Counseling from Gonzaga University and another master's degree in clinical psychology from the University of Utah. Her areas of focus include trauma and suicide among first responders and military personnel. Kelsi can be contacted at kelsi.rugo@va.gov.
Victoria Steigerwald, B.A., B.M., is a clinical psychology doctoral student at the University of Central Florida. She is currently part of UCF RESTORES, a treatment clinic and clinical research center serving individuals with PTSD. Her research focuses on identifying ways to improve the effectiveness of PTSD treatments and to integrate mental health services into the work and culture of first responders and military personnel. Victoria can be contacted at Victoria.Steigerwald@ucf.edu and can be found on Twitter @vls_psych.
Lauren M. Sippel, PhD is an Associate Director of the VA Northeast Program Evaluation Center, an Assistant Professor of Psychiatry at the Geisel School of Medicine at Dartmouth, and an affiliate of the National Center for PTSD. Her research focuses on the impact of trauma on interpersonal relationships and the implications for resilience, early intervention, and treatment. Her clinical interests include delivery of couples therapy for PTSD and trauma-informed interventions for anger. Dr. Sippel can be contacted at lauren.m.sippel@dartmouth.edu and found on Twitter at @LaurenSippelPhD.
Ryan Holliday, PhD, is a Clinical Research Psychologist at the Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention and Assistant Professor at the University of Colorado Anschutz Medical Campus. His clinical and research interest focus upon understanding the intersection of trauma, psychosocial stressors (such as homelessness and justice involvement), and mental health. He is further interested in translating these findings into evidence-based practice. Dr. Holliday can be contacted at Ryan.Holliday@va.gov and found on Twitter at @ryanpholliday.
Erika M. Roberge, PhD is a clinical investigator and staff psychologist on the PTSD and Dialectical Behavior Therapy Teams at the Salt Lake City VAMC. She is the principal investigator of the SLC VAMC’s PTSD Research Clinic where she studies patient and treatment variables that influence effectiveness of cognitive processing therapy for PTSD, as well as the relationships between trauma, suicide risk, and insomnia in the onset and maintenance of each of these presenting concerns. She is also a trainer of Crisis Response Planning for the state of Utah. She can be contacted at Erika.Roberge@va.gov.
Philip Held, PhD is an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Rush University Medical Center. He is also the Research Director for the Road Home Program: National Center of Excellence for Veterans and Their Families at Rush. Dr. Held’s research focuses on improving the efficiency and efficacy of existing evidence-based PTSD treatments, with a special focus on massed and intensive treatments, as well as utilizing personalized medicine approaches to determine for whom and under what conditions these treatments work. Dr. Held can be contacted at Philip_Held@rush.edu and can be found on Twitter @Philip_Held
Dr. Natalie Mota, PhD is an Associate Professor in the Departments of Clinical Health Psychology and Psychiatry at the University of Manitoba, and a Clinical Psychologist at the Operational Stress Injury Clinic in Winnipeg, Canada. Her research focuses on understanding the psychological and physical impacts of trauma exposure in military, first responder, and general populations, and on studying resilience factors that mitigate the negative effects of traumatic stress. Her clinical expertise is in the assessment and treatment of posttraumatic stress disorder and suicidal behavior. Dr. Mota can be reached at natalie.mota@umanitoba.ca.
Noelle Smith, PhD, is the Project Director for the Mental Health Residential Rehabilitation Treatment Program, Associate Director for the VA Northeast Program Evaluation Center (NEPEC), and an assistant clinical professor at Yale University School of Medicine. Her expertise are in evidence-based treatments for PTSD and suicide and in program evaluation. Dr. Smith can be contacted at noelle.smith2@va.gov.
References Cited
Department of Veterans Affairs & Department of Defense Management of Posttraumatic Stress Disorder Work Group. (2017). VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington, DC: VA Office of Quality and Performance.
Department of Veterans Affairs & Department of Defense Assessment and Management of Suicide Risk Work Group. (2019). VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. Washington, DC: VA Office of Quality and Performance.
Holliday, R., Borges, L. M., Stearns-Yoder, K. A., Hoffberg, A. S., Brenner, L. A., & Monteith, L. L. (2020). Posttraumatic stress disorder, suicidal ideation, and suicidal self-directed violence among U.S. military personnel and veterans: a systematic review of the literature from 2010 to 2018. Frontiers in Psychology, 11, 1998. https://doi.org/10.3389/fpsyg.2020.01998
May, A. M., & Klonsky, E. D. (2016). What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clinical Psychology: Science and Practice, 23(1), 5–20. https://doi.org/10.1111/cpsp.12136
Roberge, E. M., Leifker, F. R., Baker, S. N., Rozek, D. C., & Bryan, C. J. (2020). Suicide following trauma. In J. G. Beck & D. M. Sloan (Eds.), The Oxford Handbook of Traumatic Stress Disorders, Second Edition. Oxford University Press. https://doi.org/10.1093/oxfordhb/9780190088224.013.12
Rozek, D. C., & Bryan, C. J. (2020). Integrating crisis response planning for suicide prevention into trauma‐focused treatments: A military case example. Journal of clinical psychology, 76(5), 852-864.